Chapter 4 — Linkages For Mental Health and AOD Treatment

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Chapter 4 — Linkages For Mental Health and AOD Treatment Overview

Conventional boundaries between single-focus agencies have impeded the clinical progress of patients who have psychiatric disorders and alcohol and other drug (AOD) use disorders (Baker, 1991; Schorske and Bedard, 1988).

The treatment of patients with dual disorders is a clinical challenge, as well as a systems challenge, requiring innovation and coordination. The goal of this chapter is to help State and local administrators consider strategies for linkages across systems in order to improve service delivery and treatment outcomes. Profiles of patients with dual disorders demonstrate that they are more or differently disabled and require more services than patients with a single disorder. They have higher rates of homelessness and legal and medical problems. They have more frequent and longer hospitalizations and higher acute care utilization rates. For example, among patients with schizophrenia, episodes of violence and suicide are twice as likely to occur among those who abuse street drugs as among those who do not.

Treatment and social needs of patients with dual disorders differ depending on the type and severity of the disorders. Patients with dual disorders are generally less able to navigate between, engage in, and remain engaged in treatment services. Focusing on linkages highlights the fact that treatment providers, rather than patients and their families, have the responsibility for coordinating diverse and often conflicting treatment services.

Treatment must be suited to patients’ personal needs and characteristics, linking services across several different systems of care. Instead of blaming patients for poor treatment outcomes as they fall through the cracks of separate service systems, patients can be empowered and better treated when given effective options.

Collaboration across multiple systems and philosophies of care is needed to treat patients with dual disorders effectively. The systems often affected include:

  • Alcohol prevention and treatment services
  • Drug prevention and treatment services
  • Mental health treatment services
  • Criminal justice systems
  • Legal services
  • Social and welfare services
  • General health care services
  • Child and adult protective services
  • Vocational rehabilitation programs
  • Housing agencies
  • Agencies for homeless people
  • Educational systems
  • HIV/AIDS prevention and treatment services.

For the treatment of patients with dual disorders, the primary systems involved are AOD and mental health treatment. Programs that focus on dual disorders operate in both the mental health and AOD systems. Staff and administrative initiative is required to collaborate across systems. At a minimum, both systems should be involved when developing initiatives to improve linkages. This TIP is focused on the linkages between these systems.

In order to work effectively together, AOD treatment providers and mental health professionals need to understand and respect the different historical and philosophical underpinnings of both systems. As explained in the third chapter, the systems developed separately. There are inherent stresses and strengths among medical, psychoanalytic, psychosocial, and self-help care orientations, as well as between AOD treatment and mental health treatment.

These differences have frequently been a source of conflict and have caused problems for some patients. For example, if a patient with a dual disorder is told by his psychiatrist that he needs psychotropic medication to treat his psychiatric disorder, but members of his self-help AA group tell him to give up all mood-altering drugs to recover from his AOD abuse, to whom does he listen?

Patients with dual disorders challenge the treatment systems. Their involvement in treatment can become an opportunity for providers to examine the philosophical and practical aspects of treatment.

Providers should acknowledge that no single field has all the answers and that a need exists to integrate treatment by building upon and adapting from experience. Clinicians who work with dual disorder patients must add to their existing clinical skills. The development of a dual disorders program is an evolutionary process that requires agreed-upon outcome measures and program evaluation.

Providers should review admission criteria. These criteria should be inclusive, not exclusionary. Admission and placement criteria should be based on behaviors and skills required to participate in and benefit from a program rather than based solely on diagnosis.

Providers should find creative ways to bridge the differing funding streams, target populations, legal and regulatory mandates, and professional backgrounds and expertise.

Providers should accept the responsibility to provide integrated treatment — not parallel or concurrent treatment efforts that require the patient to integrate and adapt to different and sometimes conflicting treatment models.

In spite of the historical and philosophical differences that have separated the fields, the consensus panel identified several shared treatment concepts that administrators can use to help move toward integration.

  • Treatment should be provided in the least restrictive and most clinically appropriate setting within a continuum of care.
  • Treatment should be individualized for each patient.
  • The patient should be seen from a holistic, biopsychosocial perspective.
  • Self-help and peer support are valuable in the recovery process.
  • Families need education and support.
  • Case management plays a key role in effective treatment.
  • Multidisciplinary teams and approaches are necessary.
  • Group education and group process are valuable elements of the treatment process.
  • Ongoing support, relapse management, and prevention are necessary strategies.
  • Understanding that relapse and recovery are processes, not single events, and that relapse is not synonymous with failure is essential.
  • Cultural competence in programs and staff is required.
  • Gender-specific approaches to treatment are necessary.


Areas of Primary Concern

To establish and maintain linkages among the various systems working with patients who have dual disorders, several primary administrative areas need to be examined.

It is beyond the scope of this document to provide detailed discussion of each area, but the following discussion of problems and solutions will help readers in their problem solving. The areas to be discussed in this chapter include:

  • Policy and planning structures
  • Funding and reimbursement
  • Data collection and needs assessment
  • Program development
  • Screening, assessment, and referral
  • Case management
  • Staffing issues
  • Training and staffing
  • Linkages with social services agencies
  • Linkages with the medical health care system
  • Linkages with the criminal justice system.


Policy and Planning Structures

Problems

Often there is little or no communication or collaboration among various departments and levels of government that have separate administrative structures, constituencies, mandates, and target groups. There are also different Federal, State, and local planning cycles within the AOD use and mental health treatment systems.

The Federal Government requires two separate planning processes for programs receiving Federal funds: A State mental health plan and a State substance abuse plan. The federally mandated State planning processes required under the Public Health Service Act for mental health treatment and AOD abuse treatment are separate and have no requirements for coordination.

Solutions

Amendments are needed to the Public Health Service Act to encourage coordinated long-term planning between the State mental health and AOD abuse treatment systems for patients with dual disorders.

The development and use of long-term structural mechanisms (such as coordinating bodies, task forces, memoranda of understanding, and letters of agreement) can help improve planning for and integration of services for patients who have dual disorders.

To accomplish this goal, States might create a joint planning mechanism — an officially organized planning group — that would: 1) have diverse composition, 2) carry out specific types of tasks, and 3) maintain specific foci.

1. The planning organization should have diverse composition.
  • There should be dedicated policy-level staff from different agencies to work on the joint planning body.
  • The planning group should be culturally competent and include a culturally diverse cross-section of the population.
  • The planning group should include a significant percentage of direct recipients of the services.
  • The planning group should include family members of patients.
  • The planning group should include providers.
  • The planning group should include academic representation from schools of medicine, nursing, psychology, social work, and public health.
2. The planning group should accomplish the following tasks:
  • The group should set yearly objectives that are practical and outcome oriented, and that can be tied to observable results on the service level.
  • The group should examine existing licensing requirements and regulations that affect programs that treat patients who have dual disorders. The goal should be to make the programs compatible and to reduce duplication of licensing reviews where possible.
  • The group should alert AOD and mental health programs that provide treatment for patients with dual disorders to existing Federal and State patient protection and confidentiality laws that may be applicable for both fields.
  • The results, findings, and recommendations of the joint planning body should be formally structured to feed back into the system and ensure that the initiatives are implemented and maintained.
  • The group should recommend model policies regarding dual disorders, and stimulate initiatives in program development and training.
  • There should be collaboration with universities and colleges to develop and integrate coursework, field placements, and treatment research specific to patients with dual disorders.
  • There should be a linkage with vocational rehabilitation and employment services.
3. The planning group should maintain the following foci:
  • Define a needed array of services to address the needs of the full spectrum of patients with dual disorders.
  • Encourage county and other joint or collaborative planning with similar objectives for treating patients with dual disorders.
  • Encourage the use of funding and contracting mechanisms as incentives to ensure that services for patients with dual disorders are included.
  • Ensure that competitive contract bids to operate treatment services specify services for patients with dual disorders.
  • Award additional points to proposals for programs that address the needs of patients with dual disorders.
  • Require that local and county program plans submitted for State funds address services for dually diagnosed patients as a special population.
  • Promote training and staff development strategies to encourage acquisition of and recognition for skills in treating patients with dual disorders. The planning group should identify and disseminate information regarding the availability of Federal grants.


Funding and Reimbursement

Problems

Because of diminishing fiscal resources and competition among many interest groups for particular types of treatment, those who seek funds for the treatment of patients with dual disorders have an increasingly difficult task. In many areas, patients with dual disorders may not be recognized as a priority group for funding. No specific monies are set aside for patients with dual disorders under the block grants. The amount of funds that the Federal Government allocates to States for the AOD and mental health block grant programs changes from year to year and often includes mandated set-asides for specific groups (for example, needle users, women, etc.). Set-asides tend to be different for mental health and AOD abuse treatment and limit the amount available for special groups not specifically targeted.

States often do not take advantage of Federal monies that can be used for patients with dual disorders. It is difficult to identify Federal grants that can be used for dual disorders, since grants and announcements are scattered across many agencies such as the Substance Abuse and Mental Health Services Administration (SAMHSA), CSAT, the Center for Substance Abuse Prevention (CSAP), the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute of Mental Health (NIMH), and the Center for Mental Health Services (CMHS), to name a few.

Current reimbursement practices inhibit integration of services and effective treatment, and there are several problems related to reimbursement from both public and private third-party payers. These problems include the following:

  • There are separate monies for AOD abuse and mental health treatment.
  • The span of coverage limits the types of services that can be provided in each setting.
  • Few standards exist that define minimum benefits for either AOD abuse or mental health services.
  • Depending on the type of treatment program in which patients participate, the separation of AOD abuse services and mental health services often drives the: 1) primary diagnosis, 2) type of treatment, 3) level of treatment, and 4) level of reimbursement. This causes competition for benefits rather than cooperation.
  • Benefit funding levels vary dramatically.


Solutions

1. Facilitate the aggressive pursuit of Federal funds by the following actions:
  • Assign an individual to search for Federal grant programs serving patients with dual disorders. This can be done at the State, local, and agency levels.
  • A lead Federal agency should be identified to screen grants applicable to patients with dual disorders, and to encourage States to take advantage of potential Federal funding. (CSAT might be the lead agency.)
  • At the State level, technical assistance should be provided to screen for and assist local agencies to pursue Federal mental health and AOD funding.
2. Facilitate the use of block grant funds for treating patients with dual disorders.
  • Work to create joint funding of programs. For example, New Jersey’s Division on Alcoholism and Drug Abuse and Mental Health cofunded a number of model programs for patients with dual disorders.
  • Strive to share staff resources in programs, thus spreading out monies. For example, mental health staff can cofacilitate a dual disorders group in an AOD treatment program, and vice versa. Similarly, a mental health program can provide staff to monitor medications to avoid duplication of effort by the AOD treatment program.
  • Coordinate the provision of services and the expenditure of funds within each block grant area.
  • Encourage the allocation of more Federal dollars for block grants and set-asides that include treatment for dual disorders.
  • There may be some innovative mechanisms other than set-asides to encourage use of block grant funds for patients with dual disorders.
3. Promote Requests for Proposals (RFPs) for treating patients with dual disorders.
  • States should promote the development of RFPs specifying programs and services for patients with dual disorders.
  • State grants might give extra points for demonstrating linkages among the systems.
4. Encourage initiatives within third-party reimbursement mechanisms to cover treatment for patients with dual disorders.
  • Play an active role in keeping dual disorders a priority in health care reform efforts.
  • Encourage providers and payers to more effectively communicate with each other.
  • Encourage State-mandated benefit minimums that recognize that a more intense level of case management than usual is needed for treating patients with dual disorders.
  • Educate third-party providers that treatment for patients with dual disorders may be not only more intense but also more lengthy.
  • Consolidate and coordinate reimbursement rules for AOD abuse and mental health treatment.
  • Negotiate with local health maintenance organizations and other providers of health and mental health services to contract services for patients with dual disorders.
  • Encourage managed care companies to cover and facilitate treatment for dual disorders.
  • Encourage States to establish standards for different levels of care and requirements for staffing. Encourage the development or adoption of criteria such as those developed by the American Society of Addiction Medicine with regard to dual disorder typologies, levels of care, and reimbursement. Reimbursement should be linked to the use of criteria.

Data Collection and Needs Assessment

Problems

Only limited treatment and research data are available, and those that are available are not in a standardized format. Existing data also tend to be general and not useful to local planners for developing a continuum of care. Data collection systems are mandated to be separate from each other. It is difficult to gather prevalence data on patients with dual disorders because many of them interact with several treatment agencies or systems, while others do not interact with any.

There are systemic disincentives to gathering data on patients with dual disorders. For example, Medicaid may cover a patient who makes a suicide attempt as a result of major depression, but may not cover a patient who makes a drug-induced suicide attempt.

Solutions

At least on the State level, common identifiers in data collection should exist for both AOD abuse and mental health treatment systems. Research should be in a form that allows for evaluation of cost-effectiveness and outcome. Outcomes should be measured across several categories encompassing biopsychosocial issues. Examples might be 1) severity of AOD and psychiatric symptomatology, 2) housing, 3) service involvement and utilization, and 4) vocational involvement. Collaboration with local colleges and universities to conduct such research should be encouraged.

State planning bodies should encourage or require local needs and resource assessment and data collection. Local planners should collect data from various systems, examining and comparing data from different groups, programs, and locations. The State could gather all the data and compile them for use in improved planning and in evaluating outcomes.

Confidentiality laws must protect the patient, but also must allow for inclusion of anonymous case number data in pools to promote better assessment and treatment outcome studies.

There should be aggressive efforts to examine cost-effectiveness and outcomes of specific models of treatment services for patients with dual disorders. These research efforts can be incorporated into State and local initiatives, perhaps involving local colleges and universities.

Program Development

  • Rigid models, resistance to changing programs, and turf battles
  • Regulations and reimbursement rules
  • Clinical assumptions about dual disorders
  • Program development driven by reimbursement rules rather than by patients’ needs
  • Limited knowledge about what is effective; absence of outcome research for program models
  • Absence of good processes for disseminating information about existing programs throughout the country
  • Lack of standards for comprehensive dual disorders programs
  • Lack of incentives for good program development on the State and local levels
  • Absence of State licensing criteria specific to dual disorders
  • Lack of appropriately trained staff and other resources
  • Lack of ownership. Dual disorder treatment systems are not “owned” by the AOD abuse or mental health treatment systems. Therefore, development of dual disorder treatment programs is not a priority in either system.


Solutions

  • Provide financial incentives for integrated dual disorder treatment programs.
  • Provide grants for model program development.
  • Identify State and county dual disorder experts.
  • Publish a State bulletin to facilitate information exchange.
  • Encourage research on existing programs from both AOD abuse and mental health fields by collaborative grants between States and universities.
  • Determine how existing services can be adapted (such as with special tracks or staff training to serve the dually diagnosed population) and help define which services need to be developed and which are special and unique to groups (for example, detoxification, longer-term residential programs, halfway houses). For example, the State of New Jersey issued guidelines for a continuum of care that describe how to adapt existing AOD abuse and mental health services and what services need to be specialized to care for dual disorder patients. The guidelines serve as a blueprint for systems integration.
  • Publish a State glossary of terms to encourage communication across systems.
  • Make sure programs have integrated expertise from both AOD abuse and mental health treatment fields through a joint review process for RFPs as well as joint ongoing monitoring processes.
  • Review programs for gender and cultural competency.
  • Establish a consumer feedback process to modify programs.
  • Encourage the involvement of providers, patients, and their families in educating the public on the needs of dual disorder patients and advocating for resources.

Screening, Assessment, And Referral

Problems

The screening process amplifies the tendency to look for a single diagnosis. Staff in single-focus screening services are not trained to assess patients for dual disorders. There is no “gold standard” instrument to diagnose dual disorders. Some of the instruments that are used often yield false positive results. Screeners are not adequately trained to make effective referrals across systems, which can result in denial of treatment services. Screening for dual disorders may take longer than screening for a single disorder. For example, psychiatric symptoms can appear or disappear as the AOD-induced symptoms clear.

Solutions

  • State policies should lengthen the time frames in which screening and assessments are done for patients thought to have dual disorders. State policies should recognize that screening and assessment are ongoing processes.
  • The Federal Government should encourage research to develop standardized screening and assessment tools for dual disorders. These tools should be appropriate for people with severe and moderate AOD and psychiatric problems.
  • There should be systems-wide training of gatekeepers on the proper way to screen for dual disorders and on effective ways to make referrals.
  • There should be widespread encouragement of the multidisciplinary approach through joint staffing of screening centers or on-call backup support.


Case Management

Problems

There frequently is no single person or agency responsible for following up on referrals and ensuring that patients are linked to treatment and that services are coordinated. People with dual disorders need others to help them obtain the services that they require, which are often fragmented. The Public Health Service Act requires that State mental health agencies that receive Federal funds provide case management services to patients with severe mental illness. However, a comparable requirement is not built into the Federal mandate for AOD abuse treatment services. AOD abuse treatment agencies usually do not have enough social service staff to handle the case management functions of linkage or followup for many dual disorder patients.

Solutions

  • States and agencies need to define criteria for patients who need and do not need case management. Case management should be targeted to those who need it, while less severely ill persons should receive other services.
  • Develop multidisciplinary teams with expertise in dual disorders within AOD and mental health treatment settings. Also, encourage the use of peer counselors to help engage patients with dual disorders into appropriate treatment.
  • Encourage a continuum of case management, defining who should get what level of case management. Levels may range from treatment plan coordination while the patient is in treatment to coordinating services within the community (such as Social Security Income [SSI] and housing). Assertive mobile outreach teams can encourage out-of-treatment individuals to become engaged in treatment. These efforts can help potential patients who are reluctant to participate in treatment or who are unable to get to treatment.
  • States should help increase the case management function within the AOD abuse treatment field. Ways to develop collaboration by including AOD treatment experts in a mental health facility and in outreach operations should be found.


Staffing

Problems

All too often, treatment staff are knowledgeable about either mental health or AOD treatment. They lack thorough training and education about dual disorder patients. There is often insufficient staff time available for the level of case management required for dual disorder patients. Staff selection is often driven more by clinicians’ academic degree and their ability to provide reimbursable services than by clinicians’ expertise in dual disorders.

Solutions

  • Standards for staffing dual disorders programs should be developed. These standards should include expertise in meeting the emotional, social, psychological, biological, vocational, and recreational needs of the patient.
  • A certification process should be established for certifying clinicians who have expertise in treating dual disorders. Third-party payers should be encouraged to reimburse based on clinicians’ knowledge, competence, and expertise rather than on academic degree.


Training and Staffing

Problems

Clinicians in AOD abuse treatment and mental health treatment usually are not trained in the other discipline. The availability of staff trained in both fields is limited. Agencies frequently lack the resources to recruit and retain staff who have sufficient education and experience. There is both a shortage of qualified staff and an inability to financially compensate qualified staff for their specialized abilities. The diagnosis and treatment of dual disorders are not generally understood by staff, administrators, and legislators, let alone the general public. Agency directors and supervisors often assign whom they believe to be the most appropriate staff member to work with dual disorder patients without a clear idea of the knowledge and skills required. Professionals in AOD abuse and mental health treatment have accumulated biases against the other discipline, as well as negative stereotypes of both patients and staff. There are no structured incentives for individuals or programs to develop or take part in training, such as pay differentials and career opportunities specific to dual disorders. Opportunities and incentives for cross-training are lacking. Consumers are not adequately involved in the training process. Relatively few academic programs involve training or research in this field.

Solutions

Cross-training is one of the most effective tools administrators have for bridging gaps between clinicians and services from different fields. Training programs that provide knowledge about local networking can greatly improve linkages for patients with dual disorders.

Solutions for administrators:

Hire administrators with clinical backgrounds in dual disorders. Expose administrators to what is currently being done in the field of dual disorders through conferences, literature, visits to facilities, and visits to other States. Develop clear education and experience guidelines for different levels of staff members who treat dual disorder patients. These guidelines should be used to establish training goals with staff and to establish opportunities for advancement. Develop standards for State, local, and facility training for various levels of staff. Ensure that continuing education credits are available for both AOD abuse and mental health staff. Provide certification or credentialing for training in the other discipline to promote sensitivity in AOD and mental health treatment. Discuss with State certification board members their willingness to develop associate credentialing on AOD treatment targeted to social welfare, mental health, and criminal justice personnel. Increase awareness of dual disorders for State legislative and networking systems through appropriately detailed curricula on patients with dual disorders. Prepare a training plan for new staff and plan ongoing training for existing staff. Provide ample time to have staff fully trained (2 to 3 years). Coordinate with local universities and colleges to create a dual disorders training track.

Solutions for staff:
  • Create an individualized plan for each staff person, defining strengths as well as deficits and areas of needed growth; identify areas of greatest needs; define a training plan with a timetable and components.
  • Receive training at an established dual disorders treatment program.
  • Attend workshops on treating patients with dual disorders.
  • Include on-the-job training:
  • AOD abuse and mental health jointly facilitated groups
  • Mental health workers on an AOD abuse service
  • AOD abuse workers on a mental health service
  • Staff sharing.
  • Provide didactic inservice training:
  • Train mental health workers in AOD abuse treatment
  • Train AOD treatment staff about mental health treatment
  • Train staff in dual disorders.
  • Provide staff with important articles from the field by providing subscriptions to appropriate peer-reviewed journals. Purchase textbooks on dual disorders.
  • Work with local universities, colleges, and community college programs to create a dual disorders training track.
Solutions for the community:
  • Disseminate information to the general population through newspapers, television, and radio shows. Recovering people with dual disorders are good models.
  • Make presentations to community interest groups through speakers and speakers’ bureaus.
Solutions for consumers and their families:
  • Consumers of treatment services should be offered a role in the training process for staff in the AOD abuse and mental health fields.
  • Consumers should be included on advisory boards for nonprofit and government treatment programs.
  • Consumers should be offered the opportunity to receive training in both fields to enhance their skills as peer counselors and group cofacilitators, and to help start AA and
  • NA meetings that are sensitive to people with dual disorders, sometimes called “Double Trouble” meetings. Organizations that can help provide education to the public and patients include the National Alliance for the Mentally Ill, the National Association of Psychiatric Survivors, the National Association of Right Protection and Advocacy, and groups such as the Manic Depressive Association.
  • Families of patients should participate in Al-Anon and other support groups.

 

Linkages With Social Service Systems

Problems

A large proportion of patients with dual disorders require social services. The scope of social services is extremely broad, encompassing public and private multisystems. Federally mandated income support programs are notoriously complex, each with its own set of regulations. Some, such as the Social Security Income (SSI) maintenance program, are administered by the Federal Government, while others are administered by the State and vary from State to State. Income support programs include SSI, Medicaid, Medicare, welfare, Aid to Families With Dependent Children (AFDC), and food stamps. Regulations for each program are often not understood by professionals and others who provide services to potential recipients. This makes it even more difficult for the potential recipient to get and retain benefits. Some programs, such as SSI, require proof of a permanent and total disability. Mental health problems often do not neatly fit into categories, making it difficult to obtain this support. Income support programs for single individuals have been cut drastically in recent years. Applications for these income support programs are often taken at a site other than where either mental health or AOD services are provided for the patient. The complexity of the application and appeal process adds to the stress of a person with a dual disorder. Overburdened staff who are processing income support applications often do not understand dual disorders. Federally mandated services for children, youth, and families include services that fall under the child welfare system (for example, child protective services and foster care placement). Child welfare system staff are overburdened and understaffed. A large percentage of caseloads involve family AOD use problems. Most child welfare staff are not trained in recognizing or treating dual disorder problems. Mental health and AOD abuse staff are not trained in child welfare. There is a lack of knowledge of each other’s systems and resources. Other social service programs serve a wide range of special needs populations, including the homeless and victims of domestic violence or sexual abuse, who require a broad array of support services. Although many users of these services have mental health and AOD abuse problems, these services are often not available on site. Social service staff often lack knowledge of how to refer people with such problems into these systems.

Solutions

  • Train SSI maintenance staff about patients with dual disorders.
  • Train AOD abuse and mental health staff in a range of social service areas, including income support, child welfare, and special populations.
  • Encourage an on-site application process for income support programs at AOD abuse and mental health treatment facilities. Mental health and AOD abuse treatment programs can request training and support from Federal, State, or local administrators of various income support programs.
  • Develop mobile outreach approaches to assist patients with dual disorders in gaining access to income support programs and other needed social service programs.
  • Encourage an ongoing exchange among policy-level staff of AOD abuse, mental health, and Social Security agencies on Federal, State, and local levels.
  • Encourage a designated policy-level social services staff to create and maintain links with AOD abuse and mental health treatment systems.
  • Allocate sufficient social service staff time to assist patients who need a range of supports and services.


Linkages With the Health Care System

Problems

The medical system is vast, covering a wide range of public and private programs including primary, secondary, and tertiary care. Public primary care clinics are often overburdened, understaffed, and underfinanced. They are often oriented to treating presenting physical problems, and staff may not be trained in screening for either AOD abuse or mental health problems. The same problems often exist in nonprofit primary care facilities. Staff are often not knowledgeable about how and where to refer patients. Historically, physicians have not received any education about AOD treatment and little education about mental health problems in medical school. Primary care physicians are often unaware of the signs and symptoms of AOD use disorders, and may have only a basic understanding of a few psychiatric problems such as depression and anxiety. For example, persons who experience physical trauma, such as burn injuries or falls, often have AOD use disorders. Yet, when presented with injured patients, primary care physicians may not screen for AOD use disorders. At hospital discharge, personnel often have difficulty dealing with AOD abuse and mental health concerns. Patients are sometimes discharged inappropriately with inadequate discharge planning and linkage with aftercare services. Staff in mental health and AOD abuse treatment systems often do not know how to gain access to medical systems and therefore are ineffective in providing information and ongoing education.

Solutions

  • AOD abuse and mental health staff should take the initiative to conduct training sessions through established medical organizations such as medical societies, hospital associations, nurses’ associations, and other professional organizations.
  • AOD and mental health planning groups should publish materials that provide tips on linkage techniques for patients with dual disorders, and target such materials to the medical community.
  • Many public health clinics operated by the local health department are under the same administrative umbrella as the AOD programs. The local public health director can encourage the development of interagency training sessions, protocols, and policies and procedures to facilitate linkages between the clinics and AOD abuse treatment services and network with the mental health treatment services. Also, the local health director can help to establish stronger linkages between AOD and mental health providers with HIV/AIDS prevention and treatment systems.


Linkages With the Criminal Justice System

Problems

The criminal justice is a top-down system. There is often no mandated joint planning. The mental health system has no formal responsibility for inmates with dual disorders. Incarceration is often a substitute for AOD abuse and mental health treatment. Treatment may not begin until shortly prior to release. Medical services for the incarcerated are not reimbursable under Medicaid or any third-party payer. There is often an interagency debate regarding who should pay for care. Offenders who should be committed are often released. Prerelease assessments are often inadequate. There usually is no coordinated plan for release. No systemic funding incentives to provide care exist. There is a range of custody status. Criminal justice staff often have AOD abuse or mental health problems. There are many inadequate employee assistance programs within the criminal justice system. The criminal justice system and community AOD abuse and mental health treatment agencies may compete for the same AOD abuse and mental health treatment dollars.

Solutions

1.State
  • Establish joint top-level planning by the AOD abuse, mental health, and criminal justice fields.
  • Encourage funding that supports linkage at the service delivery level.
  • Work with AOD abuse and mental health treatment monitoring and licensing regulations to require and encourage cooperation with the criminal justice system.
  • Encourage funding for research and gathering data on persons with dual disorders in the criminal justice system.
  • Formally identify the responsibility of each system for providing specific services within the criminal justice system.
2.County and locality
  • Include representatives from the criminal justice system in local AOD abuse and mental health treatment planning groups.
  • Identify patients in each system who have an interest in cooperation.
3.Consumers
  • Educate consumer groups and the general public about the need for treatment of persons with dual disorders in the criminal justice system.
  • Encourage consumer groups to influence policy makers regarding linkages.
4.Pretrial process
  • Monitor and assess cases that involve AOD treatment and mental health treatment issues.
  • Advise and train judges regarding AOD treatment and mental health treatment options.
5.During incarceration
  • Conduct assessment for dual disorders at admission.
  • Provide treatment early in the incarceration.
  • Consider AOD abuse and mental health treatment issues during the parole hearing.
6.uring the probation-parole period
  • Conduct joint assessment by AOD, mental health, and criminal justice staff prior to release.
  • Develop a release plan that addresses AOD and mental health issues.
  • Develop a clear contingency plan to address noncompliance.
  • Establish prompt and consistent graduated sanctions of custody status.
  • Establish joint supervision of problem cases.
7.Criminal justice staff
  • Provide EAP services that assess, identify, and treat AOD and mental health problems of staff.
  • Cooperate with unions.
  • Provide training on screening and assessment.
  • Provide training to address negative attitudes of criminal justice personnel regarding AOD abuse and mental health treatment and patients with dual disorders.

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